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COUNTDOWN TO 2014: WHEN THE ACA GETS REAL — Just 406 days from now, the calendar will flip to 2014, and the most profound aspects of the Affordable Care Act will become reality. The individual mandate for millions of Americans to obtain insurance will go online, health insurance exchanges will begin providing coverage and a massive expansion of Medicaid will take effect — all of this, of course, setting the table for the midterm elections. Pro’s Jen Haberkorn breaks down the stakeholders to watch as the nation barrels toward implementation:

--HHS: “The Department of Health and Human Services’s role in bringing the law to life is going to be a lot bigger than originally thought. With only 17 states and the District of Columbia at the moment saying they’ll put together their own exchange, the administration could be responsible for setting up all or a significant part of the exchange in many of the rest of the states.”

--The states: “The states have until mid-December to tell HHS if they’re going to run their own exchange … Once the states figure out the exchange piece, the next big decision is whether to expand Medicaid. Originally mandated by the legislation, the Supreme Court last June gave states the option of expanding Medicaid or keeping it as is.

--Insurers: “Insurers are going to have rolling deadlines — likely to peak this summer — to inform the exchanges about whether they’re going to participate and what kind of health plans they want to sell …

The other key hurdle for insurers is whether people can afford the coverage.”

--Employers: “For employers, the question ahead of 2014 is whether they stick with their traditional health insurance plan for employees, or begin to push them onto the health insurance exchanges, as opponents of the law warn that they will. Some fast food and chain restaurants are signaling that they will experiment with making more workers part-time. That way the employers don’t have to cover them under the law — and don’t face hefty penalties.”

Getting healthy people to sign up for insurance, the IRS’s handling of its new ACA responsibilities and hospitals’ absorption of major cuts are also on the radar. http://politico.pro/WgYogD

Welcome to Tuesday PULSE, where we’re bemused by the macabre tradition that is the annual White House turkey pardon. Two Virginia-bred toms are en route to Washington so President Obama can decide which one lives and which one goes better with cranberry sauce: http://wj.la/TcSVJc. In case you were wondering, here’s what it looks like when presidents pardon turkeys: http://1.usa.gov/SaS4au. And here’s a disturbing 2002 CNN expose on what really happens to those protected birds: http://bit.ly/S7cliS

“I climbed up the topsails, I lost my PULSE.”

TODAY ON POLITICO PRO:

--REMEMBER THOSE MEDICARE CUTS? HERE THEY COME — It’s not just a campaign slogan anymore: The Medicare cuts included in the Affordable Care Act – all $716 billion of them – are beginning to draw blood from health care providers: http://politico.pro/S6yFci

--FEDS GEARING UP TO TAKE ON EXCHANGES, BUT THE ROAD COULD BE ROUGH — The slow drip of guidance coming from the Obama administration on how states should run health insurance exchanges looks likely to have consequences. Rather than ceding oversight of exchanges to states, as was the plan from the outset, the federal government is poised to play the role of exchange manager in as many as 30 states, putting national twist on what was supposed to be a local effort. http://politico.pro/URbJRu

--UTAH TO HHS: WHAT’S THE DEAL? – One of the only states in the nation with a functional –though not ACA-compliant — exchange wants more information about how the Obama administration would run a federal exchange and whether it could link its current system to a federal one. http://politico.pro/Uai06y

--PANEL RECOMMENDS ROUTINE HIV SCREENING — A federal task force is recommending that all Americans age 15 to 65 get routine screenings for HIV, scrapping risk based testing rating the shift “Grade A,” which could require that it be covered without a co-pay. http://politico.pro/TUj7H9

NEARLY THREE YEARS LATER, FLORIDA SENATE EYES ACA IMPLEMENTATION — Florida’s leaders are continuing to cram for the Affordable Care Act’s implementation. According to the Palm Beach Post, incoming state Senate President Don Gaetz, a Republican who had girded for the law’s repeal, plans to establish a select committee on the health law to help guide efforts to comply. Gaetz told Pro last week that he’s eyeing a so-called partnership exchange with the federal government. Gov. Rick Scott has also softened his over-my-dead-body approach to the law in recent days, pursuing a meeting with HHS Secretary Kathleen Sebelius about implementing the law. The Post story: http://bit.ly/WqiLwx

MANAGEMENT CHALLENGES FOR HHS – The HHS inspector general’s office is out with its list of top 10 management and performance challenges for the agency, and you know what No. 1 is? Hint: it involves the Affordable Care Act and fraud. “The Department and its partners should be vigilant in identifying and addressing existing and emerging fraud, waste, and abuse risk areas across all ACA-related programs,” the report states. “This will require a comprehensive approach to program integrity that integrates effective front-end program gatekeeping, sound payment design, the promotion of provider compliance, vigilant monitoring of program operations and outcomes, and rapid remediation of detected problems.” There are nine other challenges, too. The report: http://1.usa.gov/SJfMcj

PCORI TAKES ANOTHER STEP — The Patient Center Outcomes Research Institute's Board of Governors met today and approved a draft of the research methods to guide the development of comparative effectiveness research. The new standards reflect the input of public comments on a draft released earlier this year. Here it is: http://bit.ly/WgpzYM

INJUNCTION DENIED IN OKLAHOMA — A district court judge on Monday denied a request from Hobby Lobby for a preliminary injunction against the Obama administration's requirement that employers cover contraceptives without a copay. It's the second time a judge has denied a preliminary injunction request on the issue; the first denial went to the Legatus business group. Three injunctions have been granted. Judge Joe L. Heaton, who was nominated by President George W. Bush, said Hobby Lobby, as a company, doesn't have rights to the free exercise of religion. The owners, the judge said, are "unlikely to prevail" because the administration's regulations "are neutral laws of general applicability which are rationally related to a legitimate governmental objective." The Becket Fund, which is representing Hobby Lobby, said it would appeal.

FDA WORKFORCE REPORT HIGHLIGHTS CHURN/TALENT – The Innovate FDA Project at Pew Charitable Trusts released a report on the FDA workforce yesterday that finds the number of FDA employees grew 31.5 percent from 2007 to 2010 for a total of about 14,800 — and more than one quarter of them are temporary hires rather than part of the permanent workforce. Commissioned from the Partnership for Public Service, the report highlights the unique character of FDA employees — many well-paid and highly educated experts including doctors, scientists, engineers, statisticians, pharmacists, nurses, and others. One finding: FDA is losing out on talent because it takes too long to hire people, leaving key jobs vacant, and that there is more turnover among temporary employees, unsurpirsingly. It also finds that FDA employees are generally more satisfied than government workers overall. The report: http://politico.pro/SatJld

HELP COMMITTEE WANTS COMPOUNDING INSIGHT FROM STATES — Senate HELP leaders are seeking 50 sets of answers from state pharmacy overseers about their regulation of compounding facilities, the type tied to a national meningitis outbreak that has led to 33 deaths and sickened nearly 500. Sen. Tom Harkin (D-Iowa) and Sen. Mike Enzi (R-Wyo.) asked each state’s board of pharmacy registration whether they had previously filed complaints related the to the New England Compounding Center — the facility at the center of the outbreak — whether they require compounding facilities to reveal when they produce “large volumes” of drugs for sale across state lines, and whether they are required to have “patient-specific” prescriptions to produce medication. The text of the letter and the release: http://1.usa.gov/XtTu69

WHAT WE’RE READING

--Slate columnist Matthew Yglesias opines on the moves by some restaurant chains and franchises to slap new costs on their products and blame in on the Affordable Care Act: http://slate.me/UDpAoq

--Three newly elected state lawmakers speak to the Texas Tribune about what the Texas should do with the Affordable Care Act, now that it looks certain to stay on the books: http://bit.ly/100PpoA

--The Boston Globe takes a look at the efforts hospices are taking to convince the public of their value: http://b.globe.com/10jECoD

--Democrats are deeply divided over just how much they’re willing to reform Medicare as part of a fiscal cliff deal, the Wall Street Journal reports: http://on.wsj.com/UEDQgC

--Jonathan Cohn writes in the New Republic about the new tack by opponents of the Affordable Care Act — cripple it: http://bit.ly/UcbV9I

--Orlando Health hospital system is cutting up to 400 jobs, citing national health reform “mandates” and structural changes to Medicare and Medicaid, the Orlando Sentinel reports: http://thesent.nl/UQjRfk